Force Health Protection Under a Syndemic Orientation

From Force Health Protection, To Forces for Protecting Health

Force Health Protection Under a Syndemic Orientation

From Force Health Protection, To Forces for Protecting Health

Bobby Milstein 7th Annual Force Health Protection Conference

Albuquerque, NMAugust 10, 2004

Bobby Milstein 7th Annual Force Health Protection Conference

Albuquerque, NMAugust 10, 2004

“For most people peace is not the highest value. People, groups, and

governments will not renounce violence when that is seen to mean

becoming powerless and helpless in a conflict in which their basic beliefs and

the nature of their society are, or are believed to be, under attack.”

“For most people peace is not the highest value. People, groups, and

governments will not renounce violence when that is seen to mean

becoming powerless and helpless in a conflict in which their basic beliefs and

the nature of their society are, or are believed to be, under attack.”

-- Gene Sharp-- Gene Sharp

Paradox of Protecting Health in an Unhealthy Enterprise

Paradox of Protecting Health in an Unhealthy Enterprise

Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf.

“New recruits” Karen Kasmauski, National Geographic, 1988

Science, 256, (12 June 1992) pp. 1520-1521

Preparing for Inevitable ConflictPreparing for Inevitable Conflict

“Social and political theory

have neglected the central

question of means, and,

therefore, the problem of

inevitable conflict.”

“Social and political theory

have neglected the central

question of means, and,

therefore, the problem of

inevitable conflict.”

-- Joan Bondurant-- Joan Bondurant

Bondurant JV. Conquest of violence: the Gandhian philosophy of conflict. New rev. ed. Princeton N J: Princeton University Press, 1988.

Joining Fields of InquiryJoining Fields of Inquiry

PREVENTION SCIENCEPREVENTION SCIENCE

InnovativeHealth

Ventures

SYSTEM SCIENCES(improving understanding)

• What conditions protectpeople’s health and safety?

• What causes population health problems?

• How and when do health systems change?

PUBLIC HEALTH(setting goals)

What are health leaderstrying to accomplish?

SOCIAL NAVIGATION(directing movement)

Directing Change

Charting Progress

• Who does the work to effect change?• How do they act?• What do they value?

• Are conditions changing?• In what directions?

A Glimpse Into 2020A Glimpse Into 2020

Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

Rising Into Top 15

War

HIV

Violence

Self-inflicted injury

Cancer of the trachea, bronchus, and lung

Rising Into Top 15

War

HIV

Violence

Self-inflicted injury

Cancer of the trachea, bronchus, and lung

Falling Below Top 15

Measles

Malaria

Falls

Anemia

Malnutrition

Falling Below Top 15

Measles

Malaria

Falls

Anemia

Malnutrition

Public Health Goals Are Expanding…and Accumulating

Public Health Goals Are Expanding…and Accumulating

Prevent disease and injury (~1850 -- present)

Promote health and development (1974 -- present)

Assure the conditions in which people can be healthy (1988 -- present)

Prevent disease and injury (~1850 -- present)

Promote health and development (1974 -- present)

Assure the conditions in which people can be healthy (1988 -- present)

“The perfection of means and confusion of goals characterizes our age.”

-- Albert Einstein

“The perfection of means and confusion of goals characterizes our age.”

-- Albert Einstein

What does it mean to organize science and society around the goal of assuring healthful conditions?

What does it mean to organize science and society around the goal of assuring healthful conditions?

“We are redefining CDC as the nation’s

health-protection agency.”

“We are redefining CDC as the nation’s

health-protection agency.”

-- Julie Gerberding-- Julie Gerberding

Time 100: the people who shape our world. Time Magazine 2004 April 26.

Hygeia and PanaceaHygeia and Panacea“In no single thing do men approach the Gods more nearly,

than in the giving of safety to mankind.”– Cicero

“In no single thing do men approach the Gods more nearly, than in the giving of safety to mankind.”

– Cicero

Exploring the Potential of a Syndemic Orientation

Exploring the Potential of a Syndemic Orientation

Centers for Disease Control and Prevention. Spotlight on syndemics. Syndemics Prevention Network, 2001. Available at <http://www.cdc.gov/syndemics>.

http://www.cdc.gov/syndemics

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200

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Registered Members

A study of innovations in health planning and evaluation

Member network includes

244 individuals

175 organizations

11 countries

A study of innovations in health planning and evaluation

Member network includes

244 individuals

175 organizations

11 countries

New Word for a Familiar PhenomenonNew Word for a Familiar Phenomenon

Singer M, Snipes C. Generations of suffering: experiences of a treatment program for substance abuse during pregnancy. Journal of Health Care for the Poor and Underserved 1992;3(1):222-34.

Singer M. AIDS and the health crisis of the US urban poor: The perspective of critical medical anthropology. Social Science and Medicine 1994;39(7): 931-948.

Singer M. A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the SAVA syndemic. Free Inquiry in Creative Sociology 1996;24(2): 99-110.

Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly 2003;17(4):423-441.

“We have introduced the term ‘syndemic’ to refer to the set of synergistic

or intertwined and mutually enhancing health and social problems facing

the urban poor.  Violence, substance abuse, and AIDS, in this sense, are not

concurrent in that they are not completely separable phenomena.”

“We have introduced the term ‘syndemic’ to refer to the set of synergistic

or intertwined and mutually enhancing health and social problems facing

the urban poor.  Violence, substance abuse, and AIDS, in this sense, are not

concurrent in that they are not completely separable phenomena.”

-- Merrill Singer-- Merrill Singer

Focusing on RelationshipsFocusing on Relationships

The word syndemic signals special concern for many kinds of relationships:

mutually reinforcing health problems

health status and living conditions

character and composition of the health response system

The word syndemic signals special concern for many kinds of relationships:

mutually reinforcing health problems

health status and living conditions

character and composition of the health response system A syndemic orientation clarifies the

dynamic and democratic character of public health work

Health

LivingConditions

Powerto Act

Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>

“You think you understand two because you understand one and one. But you must also understand ‘and’.”

-- Sufi Saying

“You think you understand two because you understand one and one. But you must also understand ‘and’.”

-- Sufi Saying

Moving Toward a Complementary Science of Relationships

Moving Toward a Complementary Science of Relationships

Efforts to Reduce Population Health ProblemsProblem, problem solver, response

Efforts to Organize a System that Protects Population HealthDynamic interaction among multiple problems, problem solvers, and responses

Efforts to Reduce Population Health ProblemsProblem, problem solver, response

Efforts to Organize a System that Protects Population HealthDynamic interaction among multiple problems, problem solvers, and responses

Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.

Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.

“No improvements at all had been

made...open cesspools are still to

be seen...we have all the materials

for a fresh epidemic...the water-

butts were in deep cellars, close to

the undrained cesspool...The

overcrowding appears to increase."

“No improvements at all had been

made...open cesspools are still to

be seen...we have all the materials

for a fresh epidemic...the water-

butts were in deep cellars, close to

the undrained cesspool...The

overcrowding appears to increase."

Broad Street, One Year LaterBroad Street, One Year Later

-- Judith Summers-- Judith Summers

Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation

System Dynamics

SocialNavigation

POLICYDEVELOPMENT

ASSESSMENT

ASSURANCE

NetworkAnalysis

CategoricalOrientationSyndemic

Orientation

Policy ResistancePolicy Resistance

“At least six times since the

Depression, the United States has

tried and failed to enact a national

health insurance program.”

“At least six times since the

Depression, the United States has

tried and failed to enact a national

health insurance program.”

-- Lee & Paxman-- Lee & Paxman

“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”

“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”

-- Meadows, Richardson, Bruckman-- Meadows, Richardson, Bruckman

Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35.

Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.

Flaws in Previous Attempts at Health Reform in AmericaFlaws in Previous Attempts at Health Reform in America

Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999.

Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at <http://www.cpn.org/topics/health/healthquestion.html>.

Piecemeal approaches

Comprehensive strategies that are opposed by special interests

Assumption that healthcare dynamics are separate from other areas of public concern

Conventional analytic methods make it difficult to

Observe the health system as a large, dynamic enterprise

Craft high-leverage strategies that can overcome policy resistance

Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced)

Piecemeal approaches

Comprehensive strategies that are opposed by special interests

Assumption that healthcare dynamics are separate from other areas of public concern

Conventional analytic methods make it difficult to

Observe the health system as a large, dynamic enterprise

Craft high-leverage strategies that can overcome policy resistance

Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced)

“The macroscope filters details and amplifies that

which links things together. It is not used to make things

larger or smaller but to observe what is at once too

great, too slow, and too complex for our eyes.”

“The macroscope filters details and amplifies that

which links things together. It is not used to make things

larger or smaller but to observe what is at once too

great, too slow, and too complex for our eyes.”

Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html

-- Joèel de Rosnay-- Joèel de Rosnay

Looking Through the MacroscopeLooking Through the Macroscope

The Health System Exhibits Many of Our Toughest Challenges

The Health System Exhibits Many of Our Toughest Challenges

Dynamic complexityCause and effect are distant in time and space

Social complexityDiverse stakeholders with different agendas and worldviews

Adaptive complexitySolutions from the past may no longer be as effective

Dynamic complexityCause and effect are distant in time and space

Social complexityDiverse stakeholders with different agendas and worldviews

Adaptive complexitySolutions from the past may no longer be as effective

Adapted from: Senge PM. Creating desired futures in a global society. Reflections 2003;5(1):1-12.

Blood Lead Levels in the U.S. Population 1976–1999Blood Lead Levels in the U.S. Population 1976–1999

1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Year

18

2

4

6

8

10

12

14

16

Blo

od

Lea

d L

evel

s (m

g/d

L)

0

2.72.0

Unleaded gasolineintroduced

1979

Lead paint ban1976

Can solder phase-outbegins1978

Lead & copper rule1991

Can solderends1992 Leaded gas

ends1996

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Nu

mb

er o

f Cig

aret

tes

Adult Per Capita Cigarette Consumption and Major Smoking-and-Health Events

United States, 1900-1998

Adult Per Capita Cigarette Consumption and Major Smoking-and-Health Events

United States, 1900-1998

Great Depression

End of WW II

NonsmokersRights Movement Begins

1st SurgeonGeneral’s

Report

1st Smoking-Cancer Concern

Federal CigaretteTax Doubles

BroadcastAd Ban

Source: USDA; 1986 Surgeon General's Report

600

500

400

200

100

501950 1960 1970 1980 1990 1995

Rate if trend continued

Peak Rate

Actual Rate

Age-a

dju

sted D

eath

Rate

per

10

0,0

00

Popula

tion

1955 1965 1975 1985

300

700

Year

Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003.

Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998

Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998

Even the Greatest Gains are FragileEven the Greatest Gains are Fragile

“Solutions” Can Also Create New Problems“Solutions” Can Also Create New Problems

Merton RK. The unanticipated consequences of purposive social action. American Sociological Review 1936;1936:894-904.

Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.

Side Effects of SpecializationSide Effects of SpecializationConfusion, inefficiency, organizational disarray

Competition for shared resources

Attention to “local” causes, near in time and space

Neglected feedback (+ and -)

Confounded evaluations

Coercive power dynamics

Priority on a single value, implicitly or explicitly devaluing others

Limited mandate to address context (living conditions) or infrastructure (public strength)

Disappointing track record, especially with regard to inequalities

Confusion, inefficiency, organizational disarray

Competition for shared resources

Attention to “local” causes, near in time and space

Neglected feedback (+ and -)

Confounded evaluations

Coercive power dynamics

Priority on a single value, implicitly or explicitly devaluing others

Limited mandate to address context (living conditions) or infrastructure (public strength)

Disappointing track record, especially with regard to inequalities

A

C

BD

E

A B C D EIssue Organizations

Population

Diseases of DisarrayDiseases of Disarray

Hardening of the categories

Tension headache between treatment and prevention

Hypocommitment to training

Cultural incompetence

Political phobia

Input obsession

Hardening of the categories

Tension headache between treatment and prevention

Hypocommitment to training

Cultural incompetence

Political phobia

Input obsession

Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.

Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.

Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.

Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.

Dangers of Getting Too SpecificDangers of Getting Too Specific

Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.

Conventional problem solving proliferates problems

Opens a self-reinforcing niche for professional problem solvers

Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)

Conventional problem solving proliferates problems

Opens a self-reinforcing niche for professional problem solvers

Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)

Examples of Nonviolent ActionExamples of Nonviolent Action

Albert Einstein Institution. Applications of nonvilolent action. Albert Einstein Institution, 2001. http://www.aeinstein.org/.

Powers RS, Vogele WB, Kruegler C, McCarthy RM. Protest, power, and change: an encyclopedia of nonviolent action from ACT-UP to women's suffrage. New York: Garland Pub., 1997.

Dismantling dictatorships

Blocking coups d’état

Defending against foreign invasions and occupations

Providing alternatives to violence in extreme ethnic conflicts

Challenging unjust social and economic systems

Developing, preserving and extending democratic practices, human rights, civil liberties, and freedom of religion

Resisting genocide

Dismantling dictatorships

Blocking coups d’état

Defending against foreign invasions and occupations

Providing alternatives to violence in extreme ethnic conflicts

Challenging unjust social and economic systems

Developing, preserving and extending democratic practices, human rights, civil liberties, and freedom of religion

Resisting genocide

“A phenomenon that cuts across ethnic, cultural, religious,

geographic, socioeconomic and other demographic lines.”

“A phenomenon that cuts across ethnic, cultural, religious,

geographic, socioeconomic and other demographic lines.”

-- Albert Einstein Institution-- Albert Einstein Institution

SpecializationA Proven Problem Solving Approach

SpecializationA Proven Problem Solving Approach

Identify disease

Determine causes

Develop and test interventions

Implement programs and policies

Identify disease

Determine causes

Develop and test interventions

Implement programs and policies

Repeat steps 1-4, as necessary!Repeat steps 1-4, as necessary!

Identify place or population

Organize with residents/members to:

Identify afflictions and their relationships

Examine living conditions and why they differ

Devise beneficial system-wide policies

Build power to act

Direct the course of social change to assure the conditions for health for all

Expand to other places/populations, as necessary

Identify place or population

Organize with residents/members to:

Identify afflictions and their relationships

Examine living conditions and why they differ

Devise beneficial system-wide policies

Build power to act

Direct the course of social change to assure the conditions for health for all

Expand to other places/populations, as necessary

Steps in a Syndemic ApproachSteps in a Syndemic Approach

"A bad solution is bad because it acts destructively upon the

larger patterns in which it is contained...because it is formed

in ignorance or disregard of them. A bad solution solves for a

single purpose or goal, such as increased production. And it

is typical of such solutions that they achieve stupendous

increase in production at exorbitant biological and social

costs…Good solutions recognize that they are part of a larger

whole. They solve more than one problem and don't create

new problems. A good solution should not enrich one person

by the distress or impoverishment of another."

"A bad solution is bad because it acts destructively upon the

larger patterns in which it is contained...because it is formed

in ignorance or disregard of them. A bad solution solves for a

single purpose or goal, such as increased production. And it

is typical of such solutions that they achieve stupendous

increase in production at exorbitant biological and social

costs…Good solutions recognize that they are part of a larger

whole. They solve more than one problem and don't create

new problems. A good solution should not enrich one person

by the distress or impoverishment of another."

-- Wendell Berry-- Wendell Berry

Berry W. Solving for pattern. In: The Gift of Good Land. San Francisco: North Point; 1981. p. 134-45.

Solving for PatternSolving for Pattern

Senge PM. Creating desired futures in a global society. Reflections 2003;5(1):1-12.

"In problem solving we seek to make something we do not like

go away. In creating, we seek to make what we truly care

about exist… We can get so caught up in reacting to problems

that it is easy to forget what we actually want. Organizations

must do both–resolve day-to-day problems and generate new

results. But if your primary role is to fix problems, individually

or collectively, rather than create something new and

meaningful, it's hard to maintain a sense of purpose, and..it's

difficult to harness the energy, passion, commitment, and

perseverance needed to thrive in challenging times."

"In problem solving we seek to make something we do not like

go away. In creating, we seek to make what we truly care

about exist… We can get so caught up in reacting to problems

that it is easy to forget what we actually want. Organizations

must do both–resolve day-to-day problems and generate new

results. But if your primary role is to fix problems, individually

or collectively, rather than create something new and

meaningful, it's hard to maintain a sense of purpose, and..it's

difficult to harness the energy, passion, commitment, and

perseverance needed to thrive in challenging times."

Solving Problems and Creating ValueSolving Problems and Creating Value

-- Peter Senge-- Peter Senge

Misleading Framing AssumptionsMisleading Framing Assumptions

Focus on the events

Everything that happens must have a cause, and that cause must be close in time and space

Instantaneous impacts

Causality runs one-way

Independence

Impacts are linear and constant

Focus on the events

Everything that happens must have a cause, and that cause must be close in time and space

Instantaneous impacts

Causality runs one-way

Independence

Impacts are linear and constant

Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.

Basic Problem Solving OrientationsBasic Problem Solving Orientations

Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Event Oriented View

Problem Results

Goals

Situation

Decision

Basic Problem Solving OrientationsBasic Problem Solving Orientations

Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

“Side Effects”

Feedback View

Goals

Environment

Decisions

Goals ofOthers

Actions ofOthers

“Side Effects”

Delay Delay

Delay

Delay

DelayDelay

Delay

Delay

Delay

Delay

Delay

Delay

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor population health?

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor population health?

God’s will

Humors, miasma, ether

Poor living conditions, immorality (sanitation)

Single disease, single cause (germ theory)

Single disease, multiple causes (heart disease)

Single cause, multiple diseases (tobacco)

Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)

Dynamic feedback among afflictions, living conditions, and public responses (syndemic)

God’s will

Humors, miasma, ether

Poor living conditions, immorality (sanitation)

Single disease, single cause (germ theory)

Single disease, multiple causes (heart disease)

Single cause, multiple diseases (tobacco)

Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)

Dynamic feedback among afflictions, living conditions, and public responses (syndemic)

1880

1950

1960

1980

2000

1840

What happens if we shift from thinking about the variable-as-cause to the

system-as-cause?

What happens if we shift from thinking about the variable-as-cause to the

system-as-cause?

Argyris C. Actionable knowledge: design causality in the service of consequential theory. Journal of Applied Behavioral Science 1996;32(4):390-408.

Dent E. The interactional model: an alternative to the direct cause and effect construct for mutually causal organizational phenomena. Foundations of Science in press.

Richmond B. The "thinking" in systems thinking: seven essential skills. Waltham, MA: Pegasus Communications, 2000.

System-as-CauseSystem-as-Cause

“When we attribute behavior to

people rather than system structure

the focus of management becomes

scapegoating and blame rather than

the design of organizations in which

ordinary people can achieve

extraordinary results.”

“When we attribute behavior to

people rather than system structure

the focus of management becomes

scapegoating and blame rather than

the design of organizations in which

ordinary people can achieve

extraordinary results.”

-- John Sterman-- John Sterman

Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.

“The tendency to blame other people instead of the system is so strong

that psychologists call it the fundamental attribution error.”

“The tendency to blame other people instead of the system is so strong

that psychologists call it the fundamental attribution error.”

Beyond ScapegoatingBeyond Scapegoating

Health Protection as a SystemHealth Protection as a System

From: Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003.

Society's HealthResponse

Demand forresponse

Infrastructure

TargetedProtection

SaferHealthierPeople Becoming

vulnerable

Becoming saferand healthier

PrimaryPrevention

VulnerablePeople Becoming

afflicted

SecondaryPrevention

Afflictedwithout

Complications Developingcomplications

TertiaryPrevention

Afflicted withComplications

Dying fromcomplications

AdverseConditions

GeneralProtection

Adverse Effects on…

People

Environment

Civic infrastructure

Human rights

Adverse Effects on…

People

Environment

Civic infrastructure

Human rights

Assuring Healthful Conditions in War and the Preparation for War

Assuring Healthful Conditions in War and the Preparation for War

Levy BS, Sidel VW. War and public health. Updated ed. Washington DC: American Public Health Association, 2000.

Health EffectsHealth Effects Combatants Noncombatants Combatants Noncombatants

Declining Deaths Among CombatantsDeclining Deaths Among Combatants

Percent of Wounded CombatantsWho Died of Wounds, by War

13.6%

8.8%

6.1%4.5%

2.5%3.6%

6.7%

20.0%

14.0%

0%

5%

10%

15%

20%

25%

Crimean1854-1856

US Civil War(North)

1861-1865

Franco-Prussian

1870-1871

SpanishAmerican

1898

Boer War1899-1901

World War I1914-1918

World War II1941-1945

Korea 1950-1953

Vietnam1965-1973

Per

cen

t of a

ll d

eath

s

Percent of Wounded CombatantsWho Died of Wounds, by War

13.6%

8.8%

6.1%4.5%

2.5%3.6%

6.7%

20.0%

14.0%

0%

5%

10%

15%

20%

25%

Crimean1854-1856

US Civil War(North)

1861-1865

Franco-Prussian

1870-1871

SpanishAmerican

1898

Boer War1899-1901

World War I1914-1918

World War II1941-1945

Korea 1950-1953

Vietnam1965-1973

Per

cen

t of a

ll d

eath

s

Garfield RM, Neugut AI. The human consequences of war. In: Barry S. Levy VWS, editor. War and public health. Updated ed. Washington DC: American Public Health Association; 2000. p. 27-38.

Civilian Deaths as a Percentage of All Deaths,Selected 20th Century Wars

75%

90%

14%

67%

0%

20%

40%

60%

80%

100%

WW I WW II 1980s 1990s

Pe

rce

nt

of

all

de

ath

s

Civilian Deaths as a Percentage of All Deaths,Selected 20th Century Wars

75%

90%

14%

67%

0%

20%

40%

60%

80%

100%

WW I WW II 1980s 1990s

Pe

rce

nt

of

all

de

ath

s

Garfield RM, Neugut AI. The human consequences of war. In: Barry S. Levy VWS, editor. War and public health. Updated ed. Washington DC: American Public Health Association; 2000. p. 27-38.

Increasing Deaths Among NoncombatantsIncreasing Deaths Among Noncombatants

“For most people peace is not the highest value. People, groups, and

governments will not renounce violence when that is seen to mean

becoming powerless and helpless in a conflict in which their basic beliefs and

the nature of their society are, or are believed to be, under attack.”

“For most people peace is not the highest value. People, groups, and

governments will not renounce violence when that is seen to mean

becoming powerless and helpless in a conflict in which their basic beliefs and

the nature of their society are, or are believed to be, under attack.”

-- Gene Sharp-- Gene Sharp

Rethinking the ParadoxRethinking the Paradox

Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf.

“New recruits” Karen Kasmauski, National Geographic, 1988

Methods of Nonviolent ActionMethods of Nonviolent Action

Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf.

Sharp G. Correcting common misconceptations about nonviolent action. Albert Einstein Institution, 1973. Accessed May 24, 2004 at <http://65.109.42.80/organizations/org/misconceptions.pdf>.

Acts of omission (N=61 types)

-- Strikes, boycotts, civil disobedience

Acts of commission (N=137 types)

-- Blockade, sabotage, counterfeiting

Combinations of both

Acts of omission (N=61 types)

-- Strikes, boycotts, civil disobedience

Acts of commission (N=137 types)

-- Blockade, sabotage, counterfeiting

Combinations of both

“Nonviolent action has nothing to do with passivity, submissiveness, and cowardice; just as in violent conflict,

these must first be rejected and overcome.”

-- Gene Sharp

“Nonviolent action has nothing to do with passivity, submissiveness, and cowardice; just as in violent conflict,

these must first be rejected and overcome.”

-- Gene Sharp

“The strength of even dictatorships is dependent on sources of power in the society, which in turn depend on

the cooperation of a multitude of institutions and people—cooperation

which may or may not continue.”

“The strength of even dictatorships is dependent on sources of power in the society, which in turn depend on

the cooperation of a multitude of institutions and people—cooperation

which may or may not continue.”

-- Gene Sharp-- Gene Sharp

Prospects for Wielding Power through Nonviolent Action

Prospects for Wielding Power through Nonviolent Action

Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf.

Ackerman P, DuVall J. With weapons of the will: how to topple Saddam Hussein--nonviolently. Sojourners Magazine 2002(September-October).

“It is not about making a point, its about taking power.”

“It is not about making a point, its about taking power.”

-- Ackerman & DuVall-- Ackerman & DuVall

Who Will Be Our Model for Powerful Action in Conflict?Who Will Be Our Model for Powerful Action in Conflict?

AchillesAchilles AshokaAshoka

Ashoka’s StrategyAshoka’s Strategy

Security through powerful nonviolent action

Education

Transportation (roads with shade trees)

Well-digging (clean water)

Hospitals (people and animals)

Religious tolerance

Security through powerful nonviolent action

Education

Transportation (roads with shade trees)

Well-digging (clean water)

Hospitals (people and animals)

Religious tolerance

Primary Prevention for War?Primary Prevention for War?

"America was not on a road to survival before Martin Luther King. Atlanta

would not look like the thriving metropolis that it is now. Atlanta

would probably look more like Beirut if history had gone its normal course, the normal violent American way."

"America was not on a road to survival before Martin Luther King. Atlanta

would not look like the thriving metropolis that it is now. Atlanta

would probably look more like Beirut if history had gone its normal course, the normal violent American way."

-- Andrew Young-- Andrew Young

From: Kearns K. In Remembrance of Martin. PBS Video, 1999.

Academy of Achievement. Rosa Parks: pioneer of civil rights. Hall of Public Service Academy of Achievement, 2003. <http://www.achievement.org/autodoc/page/par0int-1>.

Powers RS, Vogele WB, Kruegler C, McCarthy RM. Protest, power, and change: an encyclopedia of nonviolent action from ACT-UP to women's suffrage. New York: Garland Pub., 1997.

Parks was not first to defy segregation law

Her action on December 1, 1955 was not done on a whim, but rather was part of a carefully planned NAACP legal strategy

Parks’ action was preceded by 12 years of preparation

Served as secretary of NAACP

Studied at Highlander Folk School

Parks was not first to defy segregation law

Her action on December 1, 1955 was not done on a whim, but rather was part of a carefully planned NAACP legal strategy

Parks’ action was preceded by 12 years of preparation

Served as secretary of NAACP

Studied at Highlander Folk School

“I made up my mind that I would not give in any longer to legally-imposed racial segregation.”

-- Rosa Parks

“I made up my mind that I would not give in any longer to legally-imposed racial segregation.”

-- Rosa Parks

Preparation for Nonviolent ActionPreparation for Nonviolent Action

Expanding the Fraction Conflicts that Employ Nonviolent Means

Expanding the Fraction Conflicts that Employ Nonviolent Means

Nonviolent Action & Preparation for Nonviolent Action

War & Preparation for War

“We do not hold the vision of a world without conflict.

We do hold the vision of a world without war—and this inevitably requires an alternative system

for coping with conflict.”

“We do not hold the vision of a world without conflict.

We do hold the vision of a world without war—and this inevitably requires an alternative system

for coping with conflict.”

-- Adlai Stevenson-- Adlai Stevenson

Levy BS, Sidel VW. War and public health. Updated ed. Washington DC: American Public Health Association, 2000., p. 371.

Roles for Health ProfessionalsRoles for Health ProfessionalsAs citizens,..

Reject blame, question system structure

Insist on policies to

Reduce the causes of violence

Control weapons

Strengthen capacity to engage in nonviolent action

As citizens,..

Reject blame, question system structure

Insist on policies to

Reduce the causes of violence

Control weapons

Strengthen capacity to engage in nonviolent action

Levy BS, Sidel VW. Preventing war and its health consequences: roles of public health professionals. In: Barry S. Levy VWS, editor. War and public health. Updated ed. Washington DC: American Public Health Association; 2000. p. 388-393.

As military noncombatants…

Document and analyze the full spectrum of health effects, including their dynamics

Develop a balanced portfolio of responses

Care for afflicted

Prevention for those at risk

Protection for those most vulnerable

Expand opportunities for nonviolent action

As military noncombatants…

Document and analyze the full spectrum of health effects, including their dynamics

Develop a balanced portfolio of responses

Care for afflicted

Prevention for those at risk

Protection for those most vulnerable

Expand opportunities for nonviolent action

Some Attributes of a Syndemic ViewSome Attributes of a Syndemic View

Sees the health protection enterprise in larger, more dynamic terms

Shifts from an exclusively stepwise view of change to one that is also transformational

Expands prevention science by formalizing new kinds of principles and processes (e.g., causal feedback)

Acknowledges sources of dynamic complexity and relies on analytic methods that can capture its effects

Sees the health protection enterprise in larger, more dynamic terms

Shifts from an exclusively stepwise view of change to one that is also transformational

Expands prevention science by formalizing new kinds of principles and processes (e.g., causal feedback)

Acknowledges sources of dynamic complexity and relies on analytic methods that can capture its effects

For Additional Informationhttp://www.cdc.gov/syndemics